The Chris Hani-Baragwanath hospital lies at the border of the community it serves. Coming from Johannisburg, a four lane highway leads directly to its gates – with its guards and their machine guns. From Soweto the patients stream into the hospital over a large bridge that crosses the highway in front of it. Many patients come by mini-bus and exit the busses in front of the hospital. Behind the wall surrounding its campus a large new outpatient facility has replaced the collection of barracks that had served this purpose for decades. Everything about Baragwanath is large, its exact ranking is a matter of debate, but it is certainly one of the largest hospitals in the world. In 1997 the Guiness Book of Records reported it to be the largest, with 3294 beds.1 Some 150.000 patients are admitted to the inpatient units every year, and 60-80 babies are born every day.

Baragwanath may sound “African” to many, but it is the name of a Welsh immigrant who had a hostel at the site of the hospital. It was only joined in 1997 to the name of the prominent freedom fighter Chris Hani. Baragwanath Hospital was not planned as a hospital for Soweto, but built during the 1940s for Allied troops, but unlike others of its kind constructed to be a permanent hospital structure for black patients. The layout was in single ward pavilions linked by open corridors that catch the breeze. This makes for a sprawling campus, punctuated today by some highrises. Pavilion constructions were a popular hospital style at the time, being quick to build and easy to maintain. Pavilions are structurally simple, need no elevators, and the piping is not complex. After six months of construction the first patient could be admitted in 1942. Helped by the dry South African climate the hospital became quickly occupied with tuberculosis patients. In 1948 Baragwanath opened as a civilian hospital with 800 beds. Five years later it had grown to 1600 beds already, and it only grew from there.

When the hospital was built it was at some distance from the sprawling township that would eventually enclose it. Much of the surrounding area was not settled, but a population explosion was under way. In 1936 the black population of Johannesburg had been 200,000, but by the mid-50s the Witswatersrand was home to 1.5 Million Africans.2 Soweto (Southwestern Township) itself was only so named in 1963 to denote a collection of large developments of workers’ houses often named after the farms on which they sat. Only in 2002 were they integrated into Johannesburg. Initially the townships were intended to provide much needed accommodation for black workers. However, the development of the townships was magnified and accelerated by the desire of the apartheid regimen to eradicate established black enclaves in order to make space for white working class suburbs. The most prominent victim of this desire was Sophiatown, which saw its black population expelled in the 1950s.3

Soweto was the result of the apartheid “Native Housing Policy” based on academic housing research undertaken by idealistic architects influenced by LeCorbusier and the Garden City Movement.3 It never was a Garden City, but rather became a monotonous, dusty, gray, dull township made from 600 square foot units produced in bulk. The monotony was interrupted only by tiny areas of green affluence, or slums. In addition to shacks and mass-produced brick bungalows a large proportion of male workers from rural “homelands” were housed in hostels, far away from their families. Up to sixteen men were crowded into one room, sleeping in two- or three-tier bunks without separate lounges or kitchen.

Physical insecurity, boredom, and social alienation from families and the lack of any meaningful social integration resulted.3 Soweto became the “City of Stress”.3This stress resulted in predictable alcohol abuse and frustration-fuelled violence that filled the Baragwanath emergency room with victims of fights with guns, bottles, or knifes every weekend, but more so after paydays, a very predictable phenomenon delayed only by severe rain. While much has improved with the end of apartheid and communal buildings have gone up, Soweto is not an easy place to live in. As a result of its violence 70% of the patients at the hospital are admitted for trauma.

On the medical side Soweto’s social conditions created strong generalists who manage large numbers of patients with competence and speed. Baragwanath’s 500 physicians, almost 2000 nurses, and support staff totaling about 6700 are hardly generous numbers given the workload. Their collected practice is most accessible in two books that outline medical and surgical experiences. Appropriately, a collection of essays on topics in internal medicine “A medical miscellany”4 opens with a chapter on the “pathology of poverty”, followed by a chapter dedicated to malnutrition. “Modern surgery in Africa – The Baragwanath experience”5 opens with trauma surgery, pointing out in the second chapter on head trauma that “removal of a retained knife blade is not a surgical emergency”, even if it is lodged in the brain.5 The experience of large numbers of patients and limitations of the institution formed practice and allowed for clinical experience to take center stage, i.e., for clinical observation after penetrating peritoneal trauma rather than exploratory laparotomy or radiological examination. This practice may have grown out of the observation of the futility of the other approaches, but was rigorously evaluated based on the prospective observation of hundreds of patients.6 In addition to clinical competence the restricted means and often unreliable support services created an esprit de corps of the medical staff. The physicians who practice here are aware of their competence and proudly do their unique work apart from the resource-rich practice in the other academic hospitals of Johannesburg. Over the decades international students and physicians from literally all over the world have joined in for briefer or longer periods of time to learn for their own practice and to partake in the endeavor to help the people of Soweto.

JOERG ALBRECHT studied medicine and history of architecture at Aix-la-Chapelle, Johannisburg and Cambridge. He has worked in Germany, the UK and the US and trained in clinical pharmacology, internal medicine and dermatology. He now works as a dermatologist at the J.H. Stroger Hospital of Cook County.